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Month: January 2015

I got an e-mail recently from a Dr. Tim Race, MD, FACS. I didn’t remember knowing a Dr. Race and almost deleted it. I’m all over the Social Media these days and have gotten some increased notice because of some columns I’ve written for Physician’s Weekly. I’m happy to respond to friend requests on Facebook, and often respond to comments on my PW posts. But e-mails from people who aren’t on my friend list are uncommon and I don’t usually open them. As I said, I almost deleted the message until I noticed the subject line. “NMCB-5” it said.
That brought it back to me. I’d known a Petty Officer Race when I was the battalion surgeon for Naval Mobile Construction Battalion Five during my operational tour, the year after my internship. I had been a naïve, young (very young) doctor who went from playing at being a Naval Officer to thinking I might one day actually become one. For the first time in my life, people expected me to lead, to take sole responsibility for potentially life or death decisions and to be the expert that others turned to with questions about my area of responsibility. It was transformative.
Tim Race had been the Public Health technician for the battalion, a Third Class Petty officer, just out of C-school and a bit of a troublemaker. He took his duties seriously enough, but was smart and cocky. He had little patience with the regulations and protocols of enlisted life in the Navy. My first act as a division officer when I reported to the battalion was to convince the Master-at-Arms to let Race out of the brig so that he could do the monthly galley reefer inspection on time.
Race used to volunteer for the unpopular ‘midwatch’, the midnight to four AM watch, at the dispensary, mostly because there was no one else there to tell him what to do. I had a bad case of recurring insomnia during that deployment and used to hang out in my office rather than disturb my hut mates. Race and I often talked. I don’t recall those conversations being particularly deep or overly friendly. To me he was a bright 20 year-old kid with a bit of a chip on his shoulder. I did know that he was working on a degree in biology but not much about any future plans. Neither of us was looking much beyond the end of that deployment. Race left the battalion when we returned to Home Port and I didn’t hear from him for almost 35 years.
He finished his degree and went to Medical School on the GI Bill. He trained at Virginia and did a Colon Fellowship in Pittsburgh.
In his e-mail he told me he’d seen my column on the Etiquette of Help in Physician’s Weekly and got my e-mail from my Facebook page. He then surprised me by thanking me for setting him on the path to Medical School. He recalled our late night conversations in the dispensary on Diego Garcia and told me he’d been impressed by my commitment to going back to Bethesda to finish my training. Apparently at some point in what I though was a casual conversation, I told him that he was smart enough to be in my position one day. No one had ever told him he was a smart person. I’d earned his respect by getting him out of the brig and then letting him do his job without a lot of intrusive oversight. When I told him he could make it to Medical School, he believed me.
I struck me as I read his note that we never know how much influence our everyday actions may have on others. I recall mentors and teachers who had a profound affect on me. That isn’t unusual. But I also know that some of the people who inspired or motivated me may have had no idea that they had done so. I recently reconnected with an old high school friend whose father inspired much of my own ideal of how to be a good husband and father. I think she was surprised to hear he’d had such an affect on me, since he and I weren’t particularly close. I’m not sure he even liked me. But he became for me a sort of ideal to aspire to. I know he had no idea that he’d affected me so, but a large part of who I am as a family man is down to his example.
Dr. Race and I will try to get together sometime in the future, maybe at the ACS Clinical Congress this fall. I’m a bit humbled to have learned that I had a role in shaping his career, and wonder what effect, good or bad, I may have unwittingly had on others.

I wrote a few weeks back about a death in the trauma bay, a young man with gunshot wounds to the chest. We knew nothing about him at the time, but the paramedic report and the police presence implied he was involved in some kind of drug deal. I have recently learned that this wasn’t a drug buy gone bad, but a random shooting. The victim wasn’t even the target, but was simply in the wrong place at the wrong time.
Most people want death to be sensible. We want a reason for someone to die that satisfies the mind’s need for cause and effect. Lung disease – must have been a smoker. Heart attack – red meat, obesity, no exercise. We look for some sort of causality, no matter how feeble. We imagine a clockwork universe where everything is rational and mortality plays by the rules. The secret wish behind that desire is the belief that there is also moral justification to death; that somehow we get what we deserve.
It isn’t true. The monumental stupidity that we see daily in the trauma unit still doesn’t explain why some live and some don’t. We take comfort in the mantra that “There are no victims”, that drink or drugs or stupid decisions account for the apparent randomness of trauma, but even that is a fairy tale.
We can catalog the injuries and say this or that was the fatal trauma. We can dissect our decisions and our care and say here or there is where we could have done something differently, maybe turned things around and saved rather than lost a life. None of it is true or real.
The truth is that even when people do stupid things, injury and death follow no rational or logical pattern. We are comforted when the patient is intoxicated, or when they have taken a stupid risk, and been injured. It reinforces our desire to see cause and effect. But when the injury, or worse, when death is completely random, when a patient is literally blindsided by a random event, those comfortable illusions are destroyed. We are left with the unanswerable “Why?” Perhaps it is true that God is watching over us and maneuvering us like chess pieces. I don’t know. His ways are not the ways of man.
Meanwhile, I am praying for and working on acceptance. It is hard, but that’s why it’s called work.

Some of the best advice I ever received as a medical student was from my chief resident when I was an eager young fourth-year on my first trauma rotation. “Never run to a gunshot wound to the head,” he said. “They’ll either survive until you get there or they won’t survive no matter how fast you run.” The corollary to that axiom is “Think donor. The life you save may not be the one in the trauma bay”.
Gunshot wounds to the head are a particularly difficult type of trauma to deal with. When self inflicted, they automatically create a lot of ambivalence for the trauma team. It’s hard to work to save a life that the patient himself didn’t think was worth living. And shooting yourself in the head, unlike taking pills or cutting your wrists, is a statement of a fairly serious intent to end your life.
Mostly it is an act of despair, although sometimes it seems understandable. Not a choice I would make, but understandable for the patient. I am not a psychiatrist for a reason–I have little patience with neurotics and depressed people whose only purpose in life seems to be inflicting their own misery on everyone else around them. So depression, despair, loneliness, all the usual reasons people cite as the cause of their suicidal motivation don’t strike me as particularly valid reasons to put a gun to your head. In those cases, it’s an act of supreme selfishness.
On the other hand, a patient faced with a long and debilitating and ultimately fatal illness may see suicide as a rational act to avoid a futile and costly struggle that will have the same outcome in the end as a bullet in the brain. Again, not necessarily my choice, but understandable. I’m a firm believer in property rights. The ultimate property right is the right to decide what to do with your own life. If suicide seems a rational decision, I support your right to make that choice. Just get it right the first time and make sure no one else is hurt in the process.
That last part is the real problem with suicide. It may seem right to you, but even the most rational suicide harms those whom you leave behind. Death and grief go hand in hand, but sudden death leaves little time for the survivors to prepare or accept the loss. The thought that you would deliberately choose death over staying with people who care about you is doubly hard for the survivors to accept. It’s a very personal type of rejection and all the rational arguments about why you did it don’t change that.
As a trauma surgeon, I give families bad news on a regular basis. It isn’t something that I’m particularly good at. Although I try to put things in terms that are easily understood and give an honest assessment of the patient’s prognosis, I’m not good at offering comforting words or expressions of sympathy. Harder still is the discussion of brain death and organ donation. I believe in donation. I encourage everyone to become an organ donor. But I’m lousy at broaching the subject with families, even though it’s supposed to be part of my job. Thank God for the nurses at Donor Network who do that sort of thing very well.